Diagnostic and Statistical Manual or Mental
Disorders, 5th edition
The DSM5 is a taxonomy published by APA and
is used by all mental health professionals. It
describes all mental disorders according to
specific diagnostic criteria.
DSM-5
• Is the 2013 update to the American
Psychiatric Association’s (APA)
classification and diagnostic tool. In the
US the DSM serves as a universal
authority for psychiatric diagnosis
• The DSM-5 was published on May 18,
2013.
The DSM-5 has three purposes:
1. To provide a standardized
nomenclature and language for all
mental health professionals
2. To present defining characteristics or
symptoms that differentiate specific
diagnoses – Descriptive
symptomatology
3. To assist in identifying the underlying
causes of disorders
Section II: diagnostic criteria and codes
Neurodevelopment disorders
• “Mental retardation” has a new name:
“intellectual disability (intellectual
development disorder)”.
• Phonological disorder and stuttering are
now called communication disorders –
which include language disorder,
speech sound disorder, childhood-onset
fluency disorder, and a new condition
characterized by impaired social verbal
and nonverbal communication called
social (pragmatic) communication
disorder.
• Autism spectrum disorder incorporated
Asperger disorder, childhood
disintegrative disorder, and pervasive
development disorder not otherwise
specified (PDD-NOS) – see Diagnosis of
Asperger syndrome #DSM-5 changes.
• A new sub-category, motor disorders,
encompasses developmental
coordination a disorder, stereotypic
movement disorder, and the tic
disorders including Tourette syndrome.
Schizophrenia spectrum and other psychotic
disorders
• All types of schizophrenia were
removes from the DSM-5 (paranoid,
disorganized, catatonic,
undifferentiated, and residual).
• A major mood episode is required for
schizoaffective disorder (for a majority
of the disorder’s duration after criterion
A [related to delusions, hallucinations,
disorganized speech or behavior, and
negative symptoms such as avolition] is
met).
• Criteria for delusional disorder changes,
and it is no longer separate from shred
delusional
• Catatonia in all contexts requires 3 of a
total of 12 symptoms. Catatonia may be
a specifier for depressive, bipolar, and
psychotic disorders; part of another
medical condition; or of another
specified diagnosis.
Bipolar and related disorders
• New specifier “with mixed features” can
be applied to bipolar I disorder, bipolar
II disorder, bipolar disorder NED (not
elsewhere defines, previously called
“NOS”, not otherwise specified) and
MDD.
• Allows other specifies bipolar and
related disorder for particular
conditions
 • Anxiety symptoms are specifier (called
“anxious distress”) added to bipolar
disorder and to depressive disorders
(but are not part of the bipolar
diagnostic criteria).
Obsessive-compulsive and related disorders
Depressive disorders
• The bereavement exclusion in DSM-IV
was removed from depressive in DSM-
5.
• New disruptive mood dysregulation
disorder (DMDD) for children up to age
18 years.
• Premenstrual dysphoric disorder moved
from an appendix for further study, and
became a disorder
• Specifiers were added for mixed
symptoms and for anxiety, along with
guidance to physicians for suicidality
• The term dysthymia now also would be
called persistent depressive disorder
Anxiety disorder
• For the various forms of phobias and
anxiety disorders, DSM-5 removes the
requirement that the subject (formerly,
over 18 years old) “must recognizes
that their fear and anxiety are excessive
or unreasonable”. Also, the duration of
at least 6 months now applies to
everyone (not only to children).
• Panic attack became a specifier for all
DSM-5 disorders
• Panic disorder and agoraphobia became
two separate disorders
• Specific types of phobias became
specifiers but are not otherwise
unchanged.
• The generalized specifier for social
anxiety disorder (formerly, social
phobia) changed in favor of
performance only) (i.e., public speaking
or performance) specifier.
• Separation anxiety disorder and
selective mutism are now classified as
anxiety disorders (rather than disorders
of early onset)
• A new chapter on obsessive-compulsive
and relate disorders includes four new
disorders: excoriation (skin-picking)
disorder, hoarding disorder, substance-
/medication-induced obsessive-
compulsive and related disorder, and
obsessive-compulsive and related
disorder due to another medical
condition.
• Trichotillomania (hair-pulling disorder)
moved from “impulse-control disorders
not elsewhere classified” in DSM-IV to
an obsessive-compulsive disorder in
DSM-5
• A specifier was expanded (and added to
body dysmorphic disorder and hoarding
disorder) to allow for good or fair
insight, poor insight, and “absent
insight/delusional” (i.e., complete
conviction that obsessive-compulsive
disorder beliefs are true)
• Criteria were added to body dysmorphic
disorder to describe repetitive
behaviors or mental acts that may arise
with perceived defects or flaws in
physical appearance.
• The DSM-IV specifier “with obsessive-
compulsive symptoms” moved from
anxiety disorders to this new category
for obsessive-compulsive and related
disorders.
• There are two new diagnoses: other
specified obsessive-compulsive related
disorders, which can include body-
focused repetitive behavior disorder
(behaviors like nail biting, lip biting, and
cheek chewing, other than hair pulling
and skin picking) or obsessional
 jealousy; and unspecified obsessive-
compulsive and related disorder
Trauma and stressor related disorder
• Posttraumatic stress disorder (PTSD) is
now included in a new section titled
“Trauma- and Stressor-Related
Disorders.”
• The PTSD diagnostic clusters were
recognized and expanded from a total
of three clusters to four based on the
results of confirmatory factor analytic
research conducted since the
publication of DSM-IV
• Separate criteria were added for
children six years old or younger
• For the diagnosis of acute stress
disorder and PTSD, the stressor criteria
(Criterion A1 in DSM-IV) were modified
to some extent. The requirement for
specific subjective emotional reactions
(Criterion A2 in DSM-IV) was eliminated
because it lacked empirical support for
its utility and predictive validity.
Previously certain groups, such as
military personnel involved in combat,
law enforcement officers and other first
responders, did not meet criterion A2 in
DSM-IV because their training prepared
them to not react emotionally to
traumatic events.
• Two new disorder that were formerly
subtypes were named: reactive
attachment disorder and disinhibited
social engagement disorder.
• Adjustment disorders were moved to
this new section reconceptualized as
stress-response syndromes. DSM-IV
subtypes for depressed mood, anxious
symptoms, and disturbed conduct are
unchanged.
Dissociative disorders
• Depersonalization disorder is now
called depersonalization/derealization
disorder.
• Dissociative fugue became a specifier
for dissociative amnesia.
• The criteria for dissociative identity
disorder were expanded to include
“possession-form phenomena and
functional neurological symptoms”. It is
made clear that “transitions in identity
may be observable by others or self-
reported”. Criterion B was also modified
for people who experience gaps in
recall of everyday events (not only
trauma).
Somatic symptom and related disorders
• Somatoform disorders are now
called somatic symptom and related
disorders
• Patients that present with chronic
pain can now be diagnosed with the
mental illness somatic symptom
disorder with predominant pain: or
psychological factors that affect
other medical conditional or with
an adjustment disorder.
• Somatization disorder and
undifferentiated somatoform
disorder were combined to become
somatic symptom disorder, a
diagnosis which no longer requires
a specific number of somatic
symptoms.
• Somatic symptom and related
disorders are defined by positive
symptoms, and the use of medically
unexplained symptoms is
minimized, except in the case of
conversion disorder and
pseudocyesis (false pregnancy)
• A new diagnosis is psychological
factors affecting other medical
conditions. This was formerly found
 in DSM-IV chapter “Other
Conditions That May Be a Focus of
Clinical Attention”.
• Criteria for conversion disorder
(functional neurological symptom
disorder) were changed.
Feeding and eating disorders
Sexual dysfunctions
• Criteria for pica and rumination
disorder were changed and can now
refer to people of any age
• Binge eating disorder graduated from
DSM-IV’s “Appendix B – Criteria Sets
and Axes Provided for Further Study”
into a proper diagnosis
• Requirements for bulimia nervosa and
binge eating disorder were changed
from “at least twice weekly for 6
months to at least once weekly over the
last 3 months”
• The criteria for anorexia nervosa were
changed; there is no longer
requirement of amenorrhea
• “Feeding disorder of infancy or early
childhood”, a rarely used diagnosis in
DSM-IV, was renamed to
avoidant/restrictive food intake
disorder, and criteria were expanded
Sleep-wake disorder
• “Sleep disorders related to another
mental disorder, and sleep disorders
related to a general medical condition”
Gender dysphoria
were deleted.
• Primary insomnia became insomnia
disorder, and narcolepsy is separate
from other hypersomnolence
• There are now three breathing-related
sleep disorders: obstructive sleep apnea
hypopnea, central sleep apnea, and
sleep-related hypoventilation.
• Circadian rhythm sleep-wake disorders
were expanded to include advanced
sleep phase syndrome, irregular sleep-
wake type, and non-24-hour sleep-wake
type. Jet lag was removed.
• Rapid eye movement sleep behavior
disorder and restless legs syndrome are
each a disorder, instead of both being
listed under “dyssomnia not otherwise
specified” in DSM-IV.
• DSM-IV has sex-specific sexual
dysfunctions
• For females, sexual desires and arousal
disorders are combined into female
sexual interest/arousal disorders
• Sexual dysfunctions (excepts substance-
/medication-induced sexual
dysfunction0 now require a duration of
approximately 6 months and more
exact severity criteria.
• A new diagnosis is genito-pelvic
pain/penetration disorder which
combines vaginismus and dyspareunia
from DSM-IV.
• Sexual aversion disorder was deleted.
• Subtypes for all disorders include only
“lifelong versus acquired” and
“generalized versus situational” (one
subtype was deleted from DSM-IV).
• Two subtypes were deleted: “sexual
dysfunction due to a general medical
condition” and “due to psychological
versus combined factors”.
• DSM-IV gender identity disorder is
similar to, but not the same as, gender
dysphoria in DSM-5. Separate criteria
for children, adolescents and adults that
are appropriate for varying
development states are added.
• Subtypes of gender identity disorder
based on sexual orientation were
deleted.
 • Among other wording changing,
criterion A and criterion B (Cross-gender
identification, and aversion toward
one’s gender) were combined. Along
with these changes comes the creation
of a separate gender dysphoria in
children as well as one for adults and
adolescents. The grouping has been
moved out of the sexual disorders
category and into its own. The name
change was made in part due to
stigmatization of the term “disorder”
and the relatively common use of
“gender dysphoria” in the GID literature
and among specialists in the area. The
creation of a specific diagnosis for
children reflects the lesser ability of
children to have insight into what they
are experiencing and ability to express
it in the event that they have insight.
DIC Disruptive, impulse-control, and conduct
disorders
Some of these disorders were formerly part of
the chapter on early diagnosis, oppositional
defiant disorder; conduct disorder; and
disruptive behavior disorder not otherwise
specified became other specified and
unspecified disruptive disorder, impulse-control
disorder, and conduct disorders. Intermittent
explosive disorder, pyromania, and kleptomania
moved to this chapter from the DSM-IV chapter
“impulse-Control Disorders Not Otherwise
Specified”.
• Antisocial personality disorder is listed
here and I the chapter on personality
disorders (but ADHD is listed under
neurodevelopmental disorders).
• Symptoms for oppositional defiant
disorder are of three types:
angry/irritable mood,
argumentative/defiant behavior, and
vindictiveness. The conduct disorder
exclusion is deleted. The criteria were
also changed with a note on frequency
requirements and a measure of
severity.
• Criteria for conduct disorder are
unchanged for the most part from DSM-
IV. A specifier was added for the people
with limited “prosocial emotion”,
showing callous and unemotional traits.
• People over the disorder’s minimum
age of 6 may be diagnosed with
intermittent explosive disorder without
outbursts of physical aggression.
Criteria were added for frequency and
to specify “impulsive and/or anger
based in nature, and must cause
marked distress, cause impairment in
occupational or interpersonal
functioning, or be associated with
negative financial or legal
consequences.
Substance-related and addictive disorders
• Gambling disorder and tobacco use
disorder are new
• Substance abuse and substance
dependence from DSM-IV-TR have been
combined into single substance use
disorders specific to each substance of
abuse within a new “addictions and
related disorders” category. “Recurrent
legal problems” was deleted and
“craving or a strong desire or urge to
use a substance” was added to the
criteria. The threshold of the number of
criteria that must be met was changed
and severity from mild to severe is
based on the number of criteria
endorse. Criteria for cannabis and
caffeine withdrawal were added. New
specifiers were added for early and
sustained remission along with new
specifiers for “in a controlled
environment” and “on maintenance
therapy”.
DSM-5 substance dependencies include:
• 303.90 Alcohol dependence
• 304.00 Opioid dependence
• 304.10 Sedative, hypnotic, or anxiolytic
dependence (including benzodiazepine
dependence and barbiturate
dependence
• 304.20 Cocaine dependence
• 304.30 Cannabis dependence
• 304.40 Amphetamine dependence (or
amphetamine-like)
• 304.50 Hallucinogen dependence’s
• 304.60 Inhalant dependence
• 304.80 Polysubstance dependence
• 304.90 Phencyclidine (or phencyclidine-
like dependence)
• 304.90 Other (or unknown) substance
dependence
Personality disorders
• 305.10 Nicotine dependence
There are no more polysubstance diagnoses
in DSM-5; the substance(s) must be
specified.
Neurocognitive disorders
• Dementia and amnestic disorder
became major or mild
neurocognitive disorder (major
NCD, or mild NCD). DSM-5 has a
new list of neurocognitive domains.
“New separate criteria are now
presented” for major or mild NCD
due to various conditions.
Substance/medication induced NCD
and unspecified NCD are new
diagnoses.
Paraphilic disorders
• New specifiers “in a controlled
environment” and “in remission”
were added to criteria for all
paraphilic disorders.
• A distinction is made between
paraphilic behaviors, or paraphilias,
and paraphilic disorders. All criteria
sets were changes to add the word
disorder to all of the paraphilias, for
examples, pedophilic disorder is
listed instead of pedophilia. There is
no change in the basic diagnostic
structure since DSM-III-R; however,
people now must meet both
qualitative (Criterion A) and
negative consequences (criterion B)
criteria to be diagnosed with
paraphilic disorder. Otherwise, they
have a paraphilia (and no
diagnosis).
• Personality disorder (PD) previously
belonged to a different axis than almost
all other disorders but is now in one axis
with all mental and other medical
diagnoses. However, the same ten
types of personality disorder are
retained.
• There is a call for the DSM-5 to provide
relevant clinical information that is
empirically based to conceptualize
personality as well as psychopathology
in personalities. The issue(s) of
heterogeneity of a PD is problematic as
well. For example, when determining
the criteria for a PD it is possible for two
individuals with the same diagnosis to
have completely different symptoms
that would not necessarily overlap.
There is also concern to which model is
better for the DSM – the diagnostic
model favored by psychiatrists, or the
dimensional model is favored by
psychologists. The diagnostic
approach/model is one that follows the
 diagnostic approach of traditional
medicine, is more convenient to use in
clinical settings, however, it does not
capture the intricacies of normal or
abnormal personality. The dimensional
approach/model is better at showing
varied degrees of personality; it places
emphasis on the continuum between
normal and abnormal, and abnormal as
something beyond a threshold whether
in unipolar or bipolar cases
Alternative DSM-5 model for personality
disorder
An alternative hybrid dimensional-categorical
model for personality disorders is included to
stimulate further research on this modified
classification system.
HISTORICAL PERSPECTIVE
• Ancient times: sickness represented
displeasure of Gods, punishment for
wrongdoing
• Aristotle’s theory that illness was an
imbalance of four humors (blood –
happiness, water – calmness, yellow bile –
anger, black bile – sadness) resulted in
treatments of starving, purging, and
bloodletting.
• Early Christians used exorcisms, flogging,
starving, and incarceration to rid people of
demons
• Renaissance imprisoned (1300-1600)
“dangerous lunatics” and let others wander
the countryside; witch hunts and burning at
the stake occurred in the United States in
the 1700s.
• In 1547, the Hospital of St. Mary of
Bethlehem was officially declared a hospital
for the insane
• In 1775, visitors – charged for a fee-viewing
and ridiculing the inmates (amusement)
PERIOD OF ENLIGHTENMENT AND CREATION
OF MENTAL INSTITUTIONS
• In the 1790s, a period of enlightenment
concerning persons with mental illness
began.
• Phillippe Pinel in France and William
Tukes in England formulated the
concept of asylum as a safe refuge or
haven offering protection at
institutions where people have been
whipped, beaten, ad starved just
because they were mentally ill
(Gollaher, 1995)
• Period of Enlightenment (1790s) saw
the creation of asylums or safe havens
to offer protection
• Dorothea Dix was a reformer in the
United States
The period of enlightenment was short-lived.
Within 100 years after establishment of the first
asylum, state hospitals were in trouble
1. Attendants were accused of abusing
residents
2. The rural location of hospitals was viewed as
isolating patients from family and their homes
3. and the phrase “insane asylum” took on a
negative connotation.
SIGMUND FREUD AND TREATMENT OF
MENTAL DISORDERS
• The period of scientific study and
treatment of mental disorders began
with Sigmund Freud (1856-1939) and
others such as Emil Kraepelin (1856-
1926) and Eugene Bleuler (1857-1939)
• Kraepelin began classifying mental
disorders according to their symptoms
• And Bleuler coined the term
“schizophrenia”
DEVELOPMENT OF PSYCHOPHARMACOLOGY
• About 1950 – the development of
psychotropic drugs (drugs used to treat
mental illness)
• Chlorpromazine (Thorazine), an
antipsychotic drug
• And lithium, and antimanic agent
• mental illness, including substance
DEVELOPMENT OF PSYCHOPHARMACOLOGY
● Over the following 10 years, monoamine
oxidase inhibitor antidepressants;
● Haloperidol (Haldol), an antipsychotic;
● Tricyclic antidepressants; and
antianxiety agents called
benzodiazepines were introduced.
● For the first time, drugs actually reduced
agitation, psychotic thinking, and
depression.
MOVE TOWARD COMMUNITY MENTAL HEALTH
➢ Deinstitutionalization:
- A deliberate shift from
institutional care in state
hospitals to community facilities
began.
Three components:
1. Release of individuals from state
institutions (which was geographically
isolated from family and friends)
2. Diversion from hospitalization,
3. And development of alternative
community
MENTAL ILLNESS IN THE 21ST CENTURY
● 56 millions Americans have a mental
illness (DHHS, 2002)
● Hospitals stay shorter, but more
numerous: revolving door effect. - due
to lack of funding for adequate
community services.
● Increased aggression among mentally ill
clients
● An increased number of people with
mental illness are incarcerated
● Homeless population of persons with
abuse, is growing
● Most health care dollars still spent on
inpatient psychiatric care; community
services not adequately funded
● Healthy people 2020 mental health
objectives strive to improve care of
mentally ill persons
● community-based care includes
community support services, housing,
case management, residential services
outside the hospital (see chap. 4)
● Cost containment efforts include
utilization review, HMOs, managed care,
case management
● Cultural considerations: diversity
increasing in U.S. in terms of ethnicity
and changing family structures
PSYCHIATRIC NURSING PRACTICE
● Psychiatric nursing practice emerged in
1873 when Linda Richards said, “The
mentally sick should be at least as well
cared for as the physically sick”
● 1882 was first formal training of nurses
in mental health
● First psychiatric textbook in 1920
● This is a relatively new field in
comparison with other areas
● Standards of Psychiatric-Mental Health
Clinical Nursing Practice developed in
1973, revised in 1982, 1994, 2000
● Psychiatric Mental Health Nursing
Phenomena of Concern: 12 areas of
 concern that mental health nurses focus
on when caring for client
STUDENT CONCERNS
● Saying the wrong thing
● What student will be doing
● Fear of no one talking to student
● Bizarre or inappropriate behavior
● Physical safety
● Seeing someone known to the student
SELF-AWARENESS ISSUES
● Everyone has values, beliefs, ideas;
nurses need to know what theirs are,
not to change them, but to prevent
unknown or undue influence on their
nursing practice
● Hints to increase self-awareness: keep a
journal, talk to trusted coworkers,
examine points of view other than one’s
own
“Enjoying mental health means having a sense
of wellbeing, being able to function during
everyday life and feeling confident to rise to a
challenge when the opportunity arises. Just like
your physical health, there are actions you can
take to increase your mental health. ”
BOOST YOUR WELLBEING AND STAY MENTALLY
HEALTHY BY FOLLOWING A FEW SIMPLE STEPS.
➢ Connect with others.
- Develop and maintain strong
relationships with people
around you who will support
and enrich your life.
- The quality of our personal
relationships has a great effect
on our wellbeing. Putting time
and effort into building strong
relationships can bring great
rewards.
➢ Take time to enjoy.
- Set aside time for activities,
hobbies and projects you enjoy.
Let yourself be spontaneous and
creative when the urge takes
you.
- Do a crossword; take a walk in
your local park; read a book;
sew whatever takes your fancy.
➢ Participate and share interests.
- Join a club or group of people
who share your interests. Being
part of a group of people with a
common interest provides a
sense of belonging and is good
for your mental health
➢ Contribute to your community.
- Volunteer your time for a cause
or issue that you care about.
Help out a neighbor, work in a
community garden or do
something nice for a friend.
➢ Take care of yourself.
- Be active and eat well- these
help maintain a healthy body.
Physical and mental health are
closely linked; it’s easier to feel
good about life if your body
feels good.
➢ Challenge yourself.
 - Learn a new skill or take on a
challenge to meet a goal.
➢ Deal with stress.
- Be aware of what triggers your
stress and how you react. You
may be able to avoid some of
the triggers and learn to
prepare for or manage others.
Stress is a part of life and affects
people in different ways.

➢ Rest and refresh.

- Get plenty of sleep. Go to bed at
a regular time each day and
practice good habits to get
better sleep. Sleep restores
both your mind and body.